RELEASE of ELIGIBILITY LETTER
I, ______________________________________________________________
(Requester - Print Name Clearly)
(Address of the Requester - Please print)
authorize the PA Department of Education - Nurse Aide Training Program, to release my eligibility letter
for enrollment in a state-approved nurse aide training program based on my FBI Criminal Background
Check provided by Cogent Systems.
I understand that only the eligibility letter will be released. If
additional information is needed to complete the FBI clearance process, a letter will be mailed to the
above address. To complete this release request, the requester (name that is printed above) must
provide the following:
Individual Receiving Approval Letter
Name on Letter of Eligibility
Address
City
___________________________________
________________________________________
___________________________________________________
________________________________ State ________ Zip _____________
Email Address
_______________________________________
Telephone Number ____________________________________
Registration Number provided by Cogent: PAE_________________________________
If applicable
Fax or mail form to the: Department of Education, Attention: NATCEP 11thFloor,
333 Market Street, Harrisburg, PA 17126 Email arichardso@pa.gov or ra-natcep@pa.gov
Fax (717) 783-6672.
I hereby declare that the above information is complete, accurate, true and correct and I authorize the
above named facility to receive by fax or mail this information. I make this declaration subject to the
penalties of 18 PA.C.S. 4904 relating to unsworn falsification to authorities.
_____________________________
(Signature of Requester)
6/15
____________
(Date signed)